A fresh look at exacerbations in COPD

For too long we have accepted a pessimistic tolerance of COPD exacerbations, yet the COVID pandemic has demonstrated that exacerbations can be reduced,^[1] and some evidence suggests certain interventions may be helpful in predicting and reducing exacerbations.^[2][3] This is important as exacerbations lead to significant morbidity and mortality for our patients who find these critical events terrifying.^[4] Yet, if best practice was applied, one quarter of the 30,000 deaths from COPD in England alone each year could be avoided.^[5]

Between 30% and 50% of people with COPD experience at least one exacerbation per year.^[6] A single COPD exacerbation can result in lung damage, have a detrimental impact on quality of life, and increase the risk of death.^[5]

The damage from exacerbations goes beyond the lungs – even moderate exacerbations can increase the risk of cardiovascular events, such as myocardial infarction or stroke.^[7] Despite this, significant clinical inertia appears to exist, leaving many patients under treated and at greater risk of disease progression.^[5]

Defining exacerbations

Exacerbations of COPD are defined by GOLD (2023) as ‘an event characterised by dyspnoea and/or cough and sputum that worsen over < 14 days. Exacerbations of COPD are often associated with increased local and systemic inflammation caused by airway infection, pollution, or other insults to the lungs’.^[1]  These events can be classified as mild, moderate and severe (requiring hospital admission or a visit to the Emergency Department).^[1]

These definitions of exacerbations fail to communicate the distress caused to patients, who powerfully describe feelings of panic, fear and anxiety.^[8]

Psychological distress is significantly elevated and common among patients with COPD, with up to 55% of patients suffering from actual psychiatric disorders.^[9] People with COPD who are suffering from anxiety and/or depression have an increased risk of hospital admissions and readmissions, with longer stays potentially leading to a consequent increase in costs.^[10]

Reducing the risk of exacerbations

The frequency of exacerbations varies considerably between patients with the best predictor of having frequent exacerbations (defined as two or more per year) being a history of previously treated exacerbations.^[11] Once patients start to have exacerbations, the frequency and severity increases over time.^[6] Patients with frequent exacerbations have high mortality rate with a risk of death 4.3 times greater than for patients requiring no hospital management.^[12]

It is vital then that we identify people who are having exacerbations of COPD as early as possible so that we can optimise their treatment to improve symptoms and reduce risk of exacerbations. I believe this could be achieved by taking a comprehensive history of exacerbations at diagnosis, annual reviews and at hospital discharge (for acute exacerbation of COPD). Audit of primary care records can also identify smokers, age 40 years or older, without a current diagnosis of COPD, who have required antibiotics or oral corticosteroids for chest infections/ bronchitis in the previous year.

Non-pharmacological interventions

Pharmacological therapy for COPD is used to reduce symptoms, reduce the frequency and severity of exacerbations, and improve exercise tolerance and health status,^[13] but what role do non-pharmacological interventions play? 

• Stopping smoking – this can reduce exacerbation risk, is known to improve survival and reduce the number of hospitalisation-requiring acute exacerbations, and should be considered a treatment for COPD.^[14]
• Flu and pneumococcal vaccination – vaccinations decrease respiratory infections and are recommended as part of COPD management.^[1]
• Pulmonary rehabilitation (PR) – whilst not directly impacting on exacerbations, PR improves exercise capacity, symptoms, and quality of life.^[1]

Further, supervised early PR reduces mortality by ~42% in patients with exacerbation of COPD.^[15] Increased deconditioning of patients because of shielding, combined with reduced access to PR throughout the pandemic means that many patients may need encouragement and support to increase their general activity.^[16] Signposting to local or online activity resources is a useful stopgap.

Observational studies of the impact of the COVID pandemic demonstrate a reduction in COPD exacerbations – most likely because of shielding measures, as opposed to patients not seeking medical assistance through fear of COVID.^[1]

Shielding measures (wearing face masks, minimising social contacts and frequent hand washing) could be considered, particularly during the winter months, in people at risk of exacerbations.^[1]

Conclusion

For too long we have practiced a pessimistic, failure-based approach to COPD management, often waiting until patients have experienced frequent exacerbations to offer optimal treatment.

We now know that early recognition of those at risk of exacerbations and appropriate interventions will reduce morbidity, mortality and the psychological distress experienced by our patients. It is time for us all to take a fresh look at exacerbations of COPD.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi).  All content in this article is for informational and educational purposes only.  Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within.

[1] Global Strategy for the Prevention, Diagnosis and Management of Chronic Obstructive Pulmonary Disease. 2023 Report. Available at: https://goldcopd.org/wp-content/uploads/2023/01/GOLD-2023-ver-1.2-7Jan2023_WMV.pdf

[2] Vestbo J, Lange P. Prevention of COPD exacerbations: medications and other controversies. ERJ Open Res. 2015;1(1):00011-2015

[3] NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. [E] Predicting and preventing exacerbations. Available at: https://www.nice.org.uk/guidance/ng115/evidence/e-predicting-and-preventing-exacerbations-pdf-6602768754

[4] Qureshi H, Sharafkhaneh A, Hanania NA. Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Ther Adv Chronic Dis. 2014;5(5):212-227

[5] PCRS UK. National COPD Policy Action plan. Available at: https://www.pcrs-uk.org/sites/default/files/National-COPD-Policy-Action-Plan.pdf

[6] Whittaker H, Rubino A, Müllerová H, et al. Frequency and Severity of Exacerbations of COPD Associated with Future Risk of Exacerbations and Mortality: A UK Routine Health Care Data Study. Int J Chron Obstruct Pulmon Dis. 2022;17:427-437

[7] Rothnie KJ, Connell O, Müllerová H, et al. Myocardial Infarction and Ischemic Stroke after Exacerbations of Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc. 2018;15(8):935-946

[8] Halpin D, Hyland M, Blake S, et al. Understanding fear and anxiety in patients at the time of an exacerbation of chronic obstructive pulmonary disease: a qualitative study. JRSM Open. 2015;6(12):2054270415614543

[9] Laurin C, Moullec G, Bacon SL, Lavoie KL. The impact of psychological distress on exacerbation rates in COPD. Ther Adv Respir Dis. 2011;5(1):3-18

[10] Pooler A, Beech R. Examining the relationship between anxiety and depression and exacerbations of COPD which result in hospital admission: a systematic review. Int J Chron Obstruct Pulmon Dis. 2014;9:315-330

[11] Su L, Qiao Y, Luo J, Huang R, Xiao Y. Exome and Sputum Microbiota as Predictive Markers of Frequent Exacerbations in Chronic Obstructive Pulmonary Disease. Biomolecules. 2022;12(10):1481

[12] Anzueto, A. Impact of exacerbations on COPD. Eur Respir Rev. 2010;19:113-118

[13] Montuschi P. Pharmacological treatment of chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2006;1(4):409-423

[14] Saeed, M.I., Sivapalan, P., Eklöf, J. et al. TOB-STOP-COP (TOBacco STOP in COPd trial): study protocol—a randomized open-label, superiority, multicenter, two-arm intervention study of the effect of “high-intensity” vs. “low-intensity” smoking cessation intervention in active smokers with chronic obstructive pulmonary disease. Trials. 2020;21(1):730

[15] Ryrsø, C.K., Godtfredsen, N.S., Kofod, L.M. et al. Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis. BMC Pulm Med. 2018;18(1):154

[16] Public Health England. Wider impacts of COVID-19 on physical activity, deconditioning and falls in older adults. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/
attachment_data/file/1010501/HEMT_Wider_Impacts_Falls.pdf